• M Reuel Friedman, Ron Stall, Anthony J Silvestre, Chongyi Wei, Steve Shoptaw, Amy Herrick, Pamela J Surkan, Linda Teplin, and Michael W Plankey.
• aDepartment of Infectious Diseases and Microbiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh bCenter for LGBT Health Research, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania cDepartment of Behavioral and Community Health Sciences, Graduate School of Public Health, University of California-San Francisco, San Francisco dDepartment of Epidemiology and Biostatistics, School of Medicine, University of California-San Francisco, San Francisco eDepartment of Family Medicine, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, California fDepartment of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland gDepartment of Medical Social Sciences, Northwestern University, Chicago, Illinois hDepartment of Medicine, Georgetown University Medical Center, Washington, DC, USA.
• AIDS. 2015 Jun 1; 29 (9): 1087-96.

ObjectivesThe objective of this study is to determine associations between intertwining epidemics (syndemics) and HIV medication adherence and viral load levels among HIV-positive MSM and to test whether adherence mediates the relationship between syndemics and viral load.DesignWe analysed participant data collected between 2003 and 2009 from the Multicenter AIDS Cohort Study, a prospective HIV/AIDS cohort study in four U.S. cities.MethodsWe conducted longitudinal analyses (repeated measures mixed models) to assess whether differences in viral load levels, undetectable viral load and self-reported HIV medication adherence were associated with count of syndemic conditions (substance use, depression symptoms and sexual risk behaviour, range 0-3), adjusting for race/ethnicity, age and income. Mediation analyses were conducted using structural equation modelling and the SAS %mediate macro.ResultsSyndemics count was associated with higher viral loads (P < 0.0001) and lower adherence (P < 0.0001). Increased counts of concomitant syndemics were associated with viral load (P < 0.01), detectable viral load (P < 0.05) and adherence (P < 0.001). Black MSM experienced worse outcomes across domains than white MSM (P < 0.0001) and experienced higher overall rates of syndemics (P < 0.01). Adherence significantly mediated the relationship between syndemics and viral load, accounting for an estimated 32.3% of the effect (P < 0.05).ConclusionEffectively lowering viral load levels among MSM has implications for both HIV/AIDS prevention and care. Our findings suggest that integrating substance use interventions, mental healthcare and sexual risk prevention into standard HIV care may be necessary to optimize treatment and Treatment as Prevention (TasP) models.

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